HHS Strong Start Initiative, Part 1: Hold on, Mama!

On February 8, 2012, HHS announced the Strong Start initiative which has two goals: (1) to reduce the number of preterm births that occur in the U.S. among at-risk women and those covered by Medicaid and (2) to begin a campaign to reduce the number of early elective deliveries occuring prior to 39 weeks for all populations.

To evidence the need for this initiative, HHS cites various statistics, that the number of premature births has increased by 36 percent in the past 20 years, and that ten percent of all deliveries are elective, occur prior to 39 weeks and are not medically necessary. This initiative will be addressed in two articles, this first article, addressing the subject of elective early deliveries, and the next, discussing preterm birth rates and how prenatal care and education might reduce them.

Reducing Elective Early Deliveries

In recent years, it has become increasingly common for expectant mothers to say that she will be induced, or that a cesarean section will be done, on a certain date, as opposed to saying when she is due. There are numerous reasons for a mother, along with her health care provider to choose to one-up Mother Nature, but not all of them are based on medical necessity.

A full-term pregnancy is defined as 39 to 40 weeks, and any baby born before 37 weeks is considered premature. According to the HHS News Release, “up to ten percent of all deliveries are scheduled as induced or surgical deliveries before 39 weeks that are not medically indicated.” Women and caregivers may choose to induce for various reasons, other than medical necessity, according to a survey cited in a recent USA Today article. Some of those reasons include:

(1) the caregiver is concerned that the mother is overdue (which is the leading reason for induction),

(2) the mother’s desire “to get the pregnancy over with,” and

(3) concern that the baby is too large.

The problem may be compounded by a misunderstanding as to what is considered full-term, as 75% of mothers think 34 to 36 weeks is full-term, according to the article from February 2011.

The risks of complications from preterm births are significant, as explained in the article. Thirty-nine weeks is necessary to fully develop, and “the last few weeks of pregnancy are critical to the development of the baby’s brain, lung, and liver,” according to the senior vice president and medical director of the March of Dimes Foundation, Dr. Alan Fleishman. Delivering early puts babies at risk for feeding and temperature problems and jaundice, and “tremendous increased costs,” according to Dr. Fleishman. Further, gestational dating may not be accurate if an ultrasound is not performed during the first trimester of pregnancy. If the dating is off by even two weeks, by inducing at what is estimated to be 39 weeks, the baby could be born prematurely (that is, in fact, at 37 weeks).

The USA Today article reported that in the U.S., somewhere between five and 40 percent of births are induced early without medical reason, and the variation is pronounced even within individual cities. Los Angeles, for example, saw between four and 29 percent induced early without medical reason, and Boston, between zero and 27 percent. Overall, 50 percent of hospitals reported early delivery rates of 12 percent or less, and 29 percent had rates of five percent or less, as determined through a hospital report prepared by Leapfrog Group, an nonprofit employer-driven hospital quality watchdog group. In January, Leapfrog reported that elective early birth rates were down in 2011, as cited by a Consumer Reports article. Sixty-five percent of hospitals reported improved performance in 2011, and the percentage of hospitals that had an early elective delivery rate of five percent or less was up to 39 percent in 2011. That same article noted, however, that 40 percent of deliveries were done early without medical need, and cites that some doctors prefer to control their scheduling. According to March of Dimes President Jennifer Howse, quoted in a recent CNN article, “[w]orking together to eliminate medically unnecessary early deliveries will reduce the emotional and financial burden of prematurity for thousands of families.”

Although it is reported that the rates of elective deliveries are on the decline, HHS still finds it to be enough of a problem to warrant it’s new Strong Start initiative. By reducing the number of elective deliveries that take place prior to 39 weeks, which is currently more than ten percent of all deliveries, the health of the mothers and infants is protected and costs are minimized. According to the initiative’s fact sheet, not only are mothers provided with safe, evidence-based care and infants are given the foundation of good physical and developmental health, but the resulting reduction of preventable C-section rates, neonatal intensive care admissions, and other complications helps keep costs down. This part of the initiative will utilize the existing Partnership for Patients program, where partners pledge to work to reduce the number of hospital-acquired conditions and hospital readmissions, to track hospitals’ efforts to reduce early elective delivery rates. The Partnership for Patients program includes as a goal improving obstetrical outcomes. Specifically, HHS will (1) implement a quality improvement platform through the program to share best practices with regard to these efforts with other hospitals, (2) gain support for the efforts through a campaign directed at providers, patients, and the public; and (3) arrange for the collection of performance data and measurement of success.

Stay tuned for the second part of this article, which will address the other goal of the initiative which is to reduce the rate of preterm births through education and prenatal care, to be published next week.